Dhala A A, Deshpande S S, Bremner S, Hempe S, Sra J S, Blanck Z, Akhtar M, Jazayeri M R
Electrophysiology Laboratory, University of Wisconsin Milwaukee-Clinical Campus.
Circulation. 1994 Oct;90(4):1799-810. doi: 10.1161/01.cir.90.4.1799.
The efficacy of transcatheter ablation of atrioventricular (AV) accessory pathways (APs) located in the posteroseptal region using a right atrial approach and radiofrequency energy was evaluated.
Fifty consecutive patients with APs in the posteroseptal region underwent radiofrequency catheter ablation. Manifest preexcitation was present in 36 patients and a concealed AP in 14. In 18 patients (group 1), the ventriculoatrial (VA) interval during orthodromic tachycardia was prolonged by 21 +/- 7 milliseconds (range, 10 to 30 milliseconds) with functional left bundle-branch block. In 16 patients (group 2), functional left bundle-branch block caused no VA interval prolongation. The remaining 16 patients (group 3) had no inducible left bundle-branch block during orthodromic tachycardia. Functional right bundle-branch block was induced in 30 patients with no effect on the VA interval. In group 1, of 14 patients with manifest preexcitation during sinus rhythm, 10 patients had a positive delta wave in lead V1. Of 10 group 2 patients with manifest preexcitation, only 5 had a positive delta wave in lead V1. In group 3, of 12 patients with manifest preexcitation, 7 exhibited a positive delta wave in lead V1. All posteroseptal APs were successfully ablated, and this was achieved via a right atrial approach in 48 patients and left ventricular approach in only 2. Successful sites were at the posteroseptal region of the tricuspid annulus (30 patients), within the terminal 1 cm of the coronary sinus including its ostium (16 patients), and at the inferomedial aspect of the right atrium posterior to the coronary sinus ostium (2 patients). The posteroseptal region of the left ventricle was the site of successful ablation in 2 patients. Six patients with a recurrence of AP conduction required a repeat ablation, with successful results in 5. Thirty-five patients had a complete electrophysiological evaluation 2 to 3 months after their successful ablation and were found to have no functioning AP. In 49 patients with a final successful ablation, no recurrence of symptoms was noted during a mean follow-up period of 12 +/- 9 months. Complications occurring in 3 patients were cardiac tamponade requiring surgical drainage and repair of a right ventricular tear, pericardial effusion with no hemodynamic consequence that spontaneously resolved, and a transient 2:1 atrioventricular block.
These data suggest that posteroseptal APs are amenable to successful ablation using a right atrial approach. Success was achieved in 47 cases (94%) in this series even though the ECG and/or electrophysiological characteristics of the posteroseptal APs of some patients were suggestive of "left-sided" pathways.
评估采用右心房途径和射频能量经导管消融位于后间隔区域的房室（AV）旁路（AP）的疗效。
连续50例后间隔区域有AP的患者接受了射频导管消融。36例患者存在显性预激，14例为隐匿性AP。18例患者（第1组）在顺向性心动过速时，随着功能性左束支传导阻滞，室房（VA）间期延长21±7毫秒（范围10至30毫秒）。16例患者（第2组），功能性左束支传导阻滞未导致VA间期延长。其余16例患者（第3组）在顺向性心动过速时未诱发左束支传导阻滞。30例患者诱发了功能性右束支传导阻滞，对VA间期无影响。在第1组，14例窦性心律时存在显性预激的患者中，10例V1导联有正向δ波。第2组10例有显性预激的患者中，仅5例V1导联有正向δ波。第3组12例有显性预激的患者中，7例V1导联有正向δ波。所有后间隔AP均成功消融，48例通过右心房途径实现，仅2例通过左心室途径实现。成功消融部位在三尖瓣环后间隔区域（30例患者）、冠状窦末段1 cm内包括其开口处（16例患者）以及冠状窦开口后方右心房的内下侧（2例患者）。2例患者的成功消融部位在左心室后间隔区域。6例AP传导复发的患者需要再次消融，5例成功。35例患者在成功消融后2至3个月进行了完整的电生理评估，发现无功能性AP。49例最终成功消融的患者中，平均随访12±9个月期间未出现症状复发。3例患者发生的并发症为心脏压塞，需要手术引流并修复右心室撕裂；心包积液，无血流动力学影响，自行消退；以及一过性2∶1房室传导阻滞。
这些数据表明，后间隔AP可采用右心房途径成功消融。本系列中47例（94%）成功，尽管部分患者后间隔AP的心电图和/或电生理特征提示为“左侧”旁路。
